Although trials in elderly increasing, better data still needed

Two studies published recently in the Journal of Clinical Oncology add to the growing body of evidence about cancer treatment in the elderly.

In an editorial accompanying the two studies, Laura C. Hanson, MD, and Hyman B. Muss, MD, of the University of North Carolina, wrote that taken together, the results highlight the paucity of clinical data regarding elderly patients.

“Geriatric cancer research in this issue of JCO is a welcome addition to the evidence base, but better clinical trial data are needed to guide care of geriatric patients with cancer,” they wrote.

Breast cancer treatment

In the first study, Mara A. Schonberg, MD, MPH, of Beth Israel Deaconess Medical Center, Boston, Mass., and colleagues used records from the SEER database to evaluate the role age plays in treatment. Data were examined for 49,616 women aged 67 and older diagnosed with breast cancer. There were 28,897 women in the cohort with stage I disease and 16,582 with stage II. Researchers said women aged 80 years or older (21.8%) were more likely than women aged 67 to 79 years to have a Charlson comorbidity index of two or higher.

Although 98.3% of patients in the study underwent some kind of surgery, researchers found that treatment with breast-conserving surgery and radiotherapy for women with stage I disease declined with age, particularly in women older than age 80 years. About 92% of women age 67 to 79 years with stage I disease underwent mastectomy or breast-conserving surgery and radiotherapy, only 66.8% of patients aged 80 years or older did so.

When treating stage I disease, women aged 80 years or older were more likely to undergo mastectomy compared with women 67 to 79 years (OR=2.1; 95% CI, 2.0-2.2). Researchers said mastectomy was the most common treatment among women aged 80 to 84 years.

In comparison, mastectomy was the most common method of treatment regardless of age in women with stage II disease. The use of standard treatment with breast-conserving surgery plus radiation or mastectomy also declined with age in women with stage II disease: 95.5% of women aged 66 to 79 years received standard treatment vs. 76.1% of women older than 80 years.

Overall, women aged older than 80 years were more likely to undergo mastectomy (OR=2.1) or breast-conserving surgery (compared with breast-conserving surgery plus radiation; OR=4.2) compared to the younger women in the study.

Women treated with mastectomy, breast-conserving surgery alone or no surgery had poorer breast cancer survival than those treated with surgery and radiotherapy, researchers wrote. However, researchers observed that the risk for dying from breast cancer was similar to the risk for dying from other causes for women treated with mastectomy or breast-conserving surgery alone.

“Schonberg and colleagues found a significantly higher risk of dying of breast cancer after age 80 and that treatment was significantly related to age and comorbidity with age as the stronger predictor — the older you are, the less treatment you get,” Hanson and Muss wrote. “Because of the descriptive and retrospective nature of this study, unmeasured variables, such as cognitive function, performance status, and patient preferences may confound the reported relationships. Still, the data from this analysis are important and suggest areas where clinical trials might be most helpful.”

Patient assessment

In the second study, Andrea Luciani, MD, of San Paolo Hospital, Italy, and colleagues set out to determine whether the Vulnerable Elders Survey-13 (VES-13) was a viable way to quickly screen elderly patients for comorbidities. The test is a 13-item function-based scoring system that considers age, self-rated health, limitations in physical function and functional disabilities and provides a simple test that is clinically relevant for identifying older people with increased degree of vulnerability.

Researchers administered VES-13 to 419 patients aged 70 years or older who had a cytologically confirmed solid or hematologic tumor. All patients then underwent a full comprehensive geriatric assessment before receiving treatment.

Comorbidities were assessed using the Cumulative Illness Rating Scale for Geriatrics, in which 14 conditions are rated from 0 (no problem) to 4 (severe or life-threatening). An index of 3 or higher is considered a sign of disability.

More than half of patients assessed (53.7%) had an index ≥ 3 with a mean value of 3.88. Researchers said 28% of patients were impaired as determined by comprehensive geriatric assessment and 25% evidenced disabilities on the age-adjusted activities of daily living and instrumental activities of daily living scales. The impairments most frequently reported on VES-13 were quality of life (42%), ability to walk (36%) and ability to perform heavy housework (70%).

Luciani and colleagues said the correlation between VES-13 and comprehensive geriatric assessment was 0.4. Compared with comprehensive geriatric assessment, the area under the curve for VES-13 was 0.83 with a sensitivity of 87% and a specificity of 62% at the cutoff value of 3.

The correlation between VES-13 and the activities of daily living and instrumental activities of daily living scales was 0.5. The area under the curve for VES-13 vs. those scales was 0.9, with a sensitivity of 0.9 and specificity of 0.7 at the cutoff value of 3.

“This study provides initial validation of the VES-13 for use as a functional screen with older patients with cancer, but shows that it does not replace comprehensive assessment,” wrote Hanson and Muss.

For more information:

• Hanson LC. J Clin Oncol. 2010;10.1200/JCO.2009.27.6022
• Luciani A. J Clin Oncol.2010;doi:10.1200/JCO.2009.25.9978.
• Schonberg MA. J Clin Oncol. 2010; doi:10.1200/JCO.2009.25.9796